Healthcare Newborn Document

HEALTHCARE NEWBORN REGISTRATION AND AUTHORIZATION

Infant Information

Infant Full Legal Name:

Date of Birth:    Time of Birth:

Sex: Male Female Other/Unknown

Birth Hospital/Place:

Birth Weight:    Gestational Age (weeks):

Attending Physician/Midwife:

Parent / Guardian Information

Insurance and Billing

Maternal and Newborn Medical History

Authorizations, Consents, and Acknowledgments

Authorization for Routine Medical Care: I hereby authorize licensed physicians, nurses, and other clinical staff of the health care facility to provide routine medical examination, diagnostic tests, vaccinations, prophylactic treatments, and any emergency interventions deemed necessary for the health and safety of the newborn named above. I understand that routine care may include physical examinations, hearing screening, metabolic/genetic screening, ocular prophylaxis, vitamin K administration, and Hepatitis B vaccination as medically indicated.

Specific Consents (check to authorize): Administer Hepatitis B vaccine to the newborn Administer Vitamin K injection Administer ocular prophylaxis (erythromycin or equivalent) Perform newborn hearing screening Perform state-required metabolic/genetic newborn screening

Information Release for Care and Billing: I authorize disclosure of the newborn's health information to insurance carriers, health care providers, and public health authorities as necessary for treatment, payment, immunization registry reporting, and public health surveillance. This authorization permits the release of laboratory results, vaccination records, and screening outcomes required by law.

Voluntary Participation and Withdrawal: I understand that my authorization is voluntary. I may withdraw this authorization at any time by submitting written notice to the health care facility; however withdrawal will not affect actions taken in reliance on this authorization prior to receipt of my written withdrawal.

Privacy Notice Acknowledgment

I acknowledge that I have been offered access to the facility's Notice of Privacy Practices describing how protected health information may be used and disclosed. I understand that I may request restrictions on certain uses and disclosures and that such requests will be considered and documented in accordance with applicable law.

Legal Certification

By signing below I certify that I am the parent or legal guardian of the newborn named in this document, or that I otherwise have legal authority to make health care decisions for the newborn. I affirm that the information provided on this form is true and complete to the best of my knowledge. I understand that false statements may be subject to penalties under applicable law.

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